An inquest into the death of Connor Wellsted concluded on March 31 this year that he died following “entrapment by a loose cot bumper causing death by way of airway obstruction”.
Coroner Dr Karen Henderson determined Connor died in May 2017 after The Children’s Trust “failed to keep Connor safe in his cot” by not properly securing the cot bumper.
Dr Henderson, assistant coroner for Surrey, published a prevention of future deaths report on Sunday.
It urges the charity to take steps to avoid similar tragedies at its facility in Tadworth, Surrey.
Following an inspection on May 21 last year, the Care Quality Commission, a health watchdog, rated The Children’s Trust, Tadworth “outstanding” – the highest of four possible ratings.
Under a heading of “points for coroner’s concerns”, Dr Henderson’s report states: “The current senior management team have not acknowledged there was a lack of transparency and openness as to how Connor died, or that the Trust did not properly investigate his death or inform the relevant statutory bodies of the circumstances of his death giving rise to concern of an ongoing lack of insight that institutional learning around serious incidents has not been accepted by the Trust.
“As a consequence, there is a need to introduce and develop robust clinical governance processes and systems to reassure the public and supervisory statutory bodies that they will be informed of any future adverse events and they will be investigated with openness, candour and transparency.”
Connor, from Sheffield, had “significant” neuro-disabilities caused by a brain injury after suffering near sudden infant death syndrome, sometimes known as cot death, when he was five weeks old.
But he “had no significant underlying physical or medical concerns” during what should have been a six-week stay for intensive neuro-rehabilitation at The Children’s Trust, Tadworth, starting on April 18, 2017, the coroner said.
However, Connor was found “unexpectedly deceased” in a nine-year-old padded cot that was “used infrequently” on the morning of May 17, 2017.
The report states the “active boy” likely stood up and held on to the cot bumper, which was not properly fixed, causing it to dislodge and trap his neck.
The coroner said the cot “had not had a yearly servicing for the previous five years”.
She claims Connor had “no regular or direct visual supervision during the night” and that police and the coroner service were not initially “fully informed of the circumstances” of his death.
Dr Henderson adds: “The scene had not been preserved. They were not told of the position Connor was found, that he had been dead for some time (likely hours) or that the padded board was initially found across his neck and that it required force by either one or two nurses for it to be pushed down to be removed.”
Key details were not shared with the pathologist who autopsied Connor either, the coroner said.
She claims this prevented a forensic post-mortem examination taking place to establish how or if the cot bumper may have contributed to his death.
She also notes the Trust compiled several serious investigations reports, but claims these also “did not acknowledge or address the role the cot bumper may have played in Connor’s death despite evidence from multiple witnesses indicating it was likely to be significant”.
Dalton Leong, chief executive at The Children’s Trust, said: “First and foremost, our thoughts remain with Connor’s family.
“Whilst we are saddened by the coroner’s findings, we accept them and sincerely apologise.
“We are an organisation that is committed to listening and responding to all feedback, even when it is difficult to hear.
“Our senior leadership team, with the full involvement of our board of trustees, has established an action group dedicated to developing new processes and systems that will address the coroner’s concerns.
“This is in addition to measures we had already put in place in the last five years since Connor’s death, including new beds and cots, and changes to our overnight monitoring policy.
“We want to reassure Connor’s family, and others, that we will do everything we can to ensure that something like this cannot happen again.”